Safe management of small bowel obstruction (SBO) depends on rapid diagnosis. The objective of this study was to determine factors predictive for operation and resulting in operative delay. A retrospective review was done of 1613 patients over 4 years (2003 to 2007) with International Classification of Diseases, 9th Revision codes for SBO. After excluding patients with incomplete clinical data, incorrectly coded, and age younger than 5 years, 872 patients were reviewed. Analysis was done for factors predictive for operation and factors associated with operative delay. Statistics was done using t test, Wilcoxon-rank-sum, and χ(2). Four hundred ninety-four patients (56.6%) underwent surgery for SBO. Three hundred seventy-eight patients (43.4%) were managed nonoperatively. Of factors examined, younger patients (P = 0.001), no previous operation (P < 0.001), and absence of adhesive disease (P < 0.001) were more likely to go to operation. Acquiring a computed tomographic scan (P = 0.029) or radiograph (P < 0.001) were the only factors that increased time to the operating room (OR). Increased time to the OR was associated with a higher incidence of bowel resection. With those with time to OR less than 24 hours, 39 of 325 patients(12%) had bowel resection versus time to OR greater than 24 hours, 23 of 80 patients (29%) required bowel resection. Identifying patients who may safely undergo nonoperative management remains difficult. Delay in operation for SBO places patients at higher risk for bowel resection.